Neuro exam

23. Which neurologic test or procedure requires the nurse to determine whether an informed consent has been obtained from the client before the test or procedure? a. Measurement of sensation using the pinprick method b. Computed tomography of the cranial vault c. Lumbar puncture for cerebrospinal fluid (CSF) sampling d. Venipuncture for autoantibody analysis

c. Lumbar puncture for cerebrospinal fluid (CSF) sampling

3. The nurse reviews laboratory data for a client who has Guillain-Barré syndrome (GBS). Which result does the nurse correlate with this disease process? a. Increased cerebrospinal fluid (CSF) protein level b. Decreased serum protein electrophoresis results c. Increased antinuclear antibodies d. Decreased immune globulin G (IgG) levels

ANS: A A lumbar puncture is performed to evaluate the CSF. An increased CSF protein level without increased cell count is a distinguishing feature of GBS. The other results are not associated with GBS.

10. During a neurologic assessment of a client, the nurse notes that the client's arms, wrists, and fingers have become flexed, and internal rotation and plantar flexion of the legs are evident. How does the nurse document these findings? a. Decorticate posturing b. Decerebrate posturing c. Atypical hyperreflexia d. Spinal cord degeneration

ANS: A The client is demonstrating decorticate posturing, which is seen with interruption in the corticospinal pathway. This finding is abnormal and is a sign that the client's condition has deteriorated. The physician, the charge nurse, and other health care team members should be notified immediately of this change in status. Decerebrate posturing consists of external rotation and extension of the extremities. The other two options are inaccurate.

19. A client is prescribed levetiracetam (Keppra). Which laboratory tests does the nurse monitor for potential adverse effects of this medication? a. Serum electrolyte levels b. Kidney function tests c. Complete blood cell count d. Antinuclear antibodies

ANS: B Adverse effects of levetiracetam (Keppra) include coordination problems and renal toxicity. The other laboratory tests are not affected by levetiracetam.

10. A client suspected to have myasthenia gravis is scheduled for the Tensilon (edrophonium chloride) test. Which prescribed medication does the nurse prepare to administer if complications of this test occur? a. Epinephrine b. Atropine sulfate c. Diphenhydramine d. Neostigmine bromide

ANS: B Tensilon increases cholinergic responses and can slow the heart rate down so that ectopic beats dominate, causing cardiac fibrillation or arrest. Atropine sulfate is an anticholinergic drug. The other medications are not appropriate for complications of this test.

25. In a client with an injury to the medulla, the nurse monitors for which clinical manifestations secondary to damage of cranial nerves that emerge from the medulla? (Select all that apply.) a. Loss of smell b. Impaired swallowing c. Blink reflex d. Visual changes e. Inability to shrug shoulders f. Loss of gag reflex

ANS: B, E, F Cranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal) emerge from the medulla, as do portions of cranial nerves VII (facial) and VIII (acoustic). Damage to these nerves causes impaired swallowing, inability to shrug shoulders, and loss of the gag reflex. The other manifestations are not associated with damage to the medulla.

27. The nurse is discussing advanced directives with a client who has amyotrophic lateral sclerosis (ALS). The client states, "I do not want to be placed on a mechanical ventilator." How does the nurse respond? a. "You will need to discuss that with your family and health care provider." b. "Why are you afraid of being placed on a breathing machine?" c. "What would you like to be done if you begin to have difficulty breathing?" d. "You will be on the ventilator only until your muscles get stronger."

ANS: C ALS is an adult-onset upper and lower motor neuron disease, characterized by progressive weakness, muscle wasting, and spasticity, eventually leading to paralysis. Once muscles of breathing are involved, the client must include in the advance directives what is to be done when breathing is no longer possible without intervention. The other statements do not address the client's needs.

3. The nurse is reviewing a client's prescription for sumatriptan succinate (Imitrex). Which condition in this client's medical history does the nurse report to the health care provider? a. Bronchial asthma b. Gonorrhea c. Prinzmetal's angina d. Chronic kidney disease

ANS: C Sumatriptan succinate effectively reduces pain and other associated symptoms of migraine by binding to serotonin receptors and triggering cranial vasoconstriction. Vasoconstrictive effects are not confined to the cranium and can cause coronary vasospasm in clients with Prinzmetal's angina. The other conditions would not affect the client's treatment.

23. The nurse is planning to bathe a client diagnosed with meningococcal meningitis. In addition to gloves, what personal protective equipment does the nurse use? a. Particulate respirator b. Isolation gown c. Shoe covers d. Surgical mask

ANS: D Meningeal meningitis is spread via saliva and droplets. Caregivers should wear a surgical mask when within 6 feet of the client and should continue to use Standard Precautions. A particulate respirator, an isolation gown, and shoe covers are not necessary for Droplet Precautions.

20. A client is scheduled for a single-photon emission computed tomography test. Which condition in the client's history causes the nurse to contact the provider before the test takes place? a. Peptic ulcers b. Smoking history c. Liver failure d. Currently breast feeding

ANS: D A SPECT test uses radiopharmaceutical agents that enable radioisotopes to cross the blood-brain barrier. This test is contraindicated in women who are breast-feeding. Having a history of smoking, peptic ulcers, or liver failure should not interfere with the client having this test.

3. The nurse is planning to provide discharge teaching related to cardiac medications to a client who has experienced damage to the left temporal lobe of the brain. What does the nurse do to assist the client to understand the content of the instruction? a. Use a larger print size for written materials. b. Ensure that the client is wearing glasses. c. Point out the color of the medication. d. Sit on the client's right side.

ANS: D The temporal lobe contains the auditory center for sound interpretation. The client's hearing will be impaired in the left ear. The nurse should sit on the client's right side and speak to the right ear. The other interventions do not address the client's left temporal lobe damage.

3. A client who has a herniated disk is being discharged after a percutaneous endoscopic discectomy. Which postprocedure instructions does the nurse provide before discharge? a. "You should begin an exercise routine which includes walking every day." b. "You must sleep in a supine position until the bandage is removed." c. "You may feel numbness or tingling in the legs for 24 hours." d. "You will need to wear a lumbar brace for 1 week."

ANS: A After this minimally invasive surgery, clients typically go home the same day or the day after surgery. Clients should be taught to begin the prescribed exercise program immediately after discharge, which includes walking every day. The client should not be restricted to one sleeping position. Clients generally have less pain with this procedure and do not experience numbness or tingling. The client may have a clear or gauze dressing but will not need to wear a lumbar brace.

13. A client who has myasthenia gravis is receiving atropine for a cholinergic crisis. Which intervention does the nurse implement for this client? a. Suction the client to remove secretions. b. Turn and reposition the client every 2 hours. c. Measure urinary output every 30 minutes. d. Administer prescribed anticholinergic drugs as needed.

ANS: A Atropine can cause thickening of secretions and formation of mucous plugs. The client is maintained on a ventilator during the crisis. Measures to remove secretions to prevent the buildup of secretions and the possibility of pneumonia are most important. The other interventions do not relate to the administration of atropine.

6. The nurse is assessing a client with a history of absence seizures. Which clinical manifestation does the nurse assess for? a. Automatisms b. Intermittent rigidity c. Sudden loss of muscle tone d. Brief jerking of the extremities

ANS: A Automatisms are characteristic of absence seizures. These behaviors consist of lip smacking, patting, and picking at clothing. The other manifestations do not correlate with absence seizures.

17. The nurse teaches a client who has autonomic dysfunction about injury prevention. Which statement indicates that the client correctly understands the teaching? a. "I will change positions slowly." b. "I will avoid wearing cotton socks." c. "I will use an electric razor." d. "I will use a heating pad on my feet."

ANS: A Autonomic dysfunction causes orthostatic hypotension. The client should change positions slowly to prevent orthostatic hypotension. Autonomic dysfunction can cause peripheral polyneuropathy, so the client should be taught to wear socks and shoes at all times and not to use a heating pad. The disorder does not cause bleeding; therefore the client can use any type of razor.

17. Which priority instruction or precaution does the nurse teach a client who is scheduled for a positron emission tomography scan of the brain? a. "Avoid caffeine-containing substances for 12 hours before the test." b. "Drink at least 3 liters of fluid during the 24 hours after the test." c. "Do not take your cardiac medication on the morning of the test." d. "Remove your dentures and any metal before the test begins."

ANS: A Caffeine-containing liquids and foods are central nervous system stimulants and may alter the test results. No contrast is used; therefore the client does not need to increase fluid intake. The test does not require MRI, so metal does not have to be removed. The client should take cardiac medications as prescribed.

13. The nurse is caring for a client post-cerebral angiography via the client's right femoral artery. Which intervention does the nurse implement? a. Check the right lower extremity pulses. b. Measure orthostatic blood pressure. c. Perform a funduscopic examination. d. Assess the client's gag reflex.

ANS: A Cerebral angiography is performed by threading a catheter through the femoral or brachial artery. The extremity is kept immobilized after the procedure. The nurse checks the extremity for adequate circulation by noting skin color and temperature, presence and quality of pulses distal to the injection site, and capillary refill. Clients usually are on bedrest; therefore orthostatic blood pressure cannot be performed. The funduscopic examination would not be affected by cerebral angiography. The client is given analgesics but not conscious sedation; therefore the client's gag reflex would not be compromised.

4. The nurse is assessing a client with a cluster headache. Which clinical manifestation does the nurse expect to find? a. Ipsilateral tearing of the eye b. Exophthalmos c. Abrupt loss of consciousness d. Neck and shoulder tenderness

ANS: A Cluster headache is usually accompanied by ipsilateral tearing, rhinorrhea or nasal congestion, ptosis, eyelid edema, facial sweating, and miosis. The other manifestations are not associated with cluster headaches.

1. The nurse is providing health education at a community center. Which instruction does the nurse include as part of client education for the prevention of low back pain? a. "Participate in a regular exercise program." b. "Purchase a soft mattress for sleeping comfort." c. "Wear high-heeled shoes only for special occasions." d. "Keep your weight within 20% of your ideal body weight."

ANS: A Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not prevent low back pain.

17. The nurse is caring for a hospitalized client with Alzheimer's disease who has a history of agitation. Which intervention does the nurse implement to help prevent agitation and aggressive behavior in this client? a. Provide undisturbed sleep. b. Orient the client to reality. c. Leave the television turned on. d. Administer hypnotic drugs as needed.

ANS: A Fatigue from disturbed sleep increases confusion and behavioral manifestations, such as aggression and agitation. Reality orientation is inappropriate for clients in a later stage of the disease. Constant noise from the TV most likely would agitate the client. Sedation should be used as a last resort.

22. While assessing pain discrimination, a client correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. How does the nurse then proceed with the examination? a. Touch the pin on the same area of the left hand. b. Touch the pin on the right forearm. c. Touch the pin on the right upper arm. d. Touch the right hand with a drop of cold water.

ANS: A If testing is begun on the hand and the client correctly identifies the pain stimulus, testing more proximal parts of that extremity is not necessary because, if the distal tract is intact, so are the proximal areas. Temperature discrimination is not necessary because the same tract transmits both pain and temperature sensation.

9. The nurse is assessing the deep tendon reflexes of a client with long-standing diabetes mellitus. Which clinical manifestation does the nurse expect to see? a. Bilateral hypoactive reflexes b. Bilateral hyperactive reflexes c. Asymmetric reflex response d. Bilateral ankle clonus

ANS: A Long-standing diabetes mellitus causes peripheral neuropathy. Hypoactive responses or no response to stimulation of deep tendon reflexes is one manifestation of diabetes-induced peripheral neuropathy. Other responses are not related to complications of diabetes mellitus.

12. The nurse is taking the health history of a client suspected of having bacterial meningitis. Which question is most important for the nurse to ask? a. "Do you live in a crowded residence?" b. "When was your last tetanus vaccination?" c. "Have you had any viral infections recently?" d. "Have you traveled out of the country in the last month?"

ANS: A Meningococcal meningitis tends to occur in outbreaks. It is most likely to occur in areas of high-density population, such as college dormitories, prisons, and military barracks. The other questions do not identify risk factors for bacterial meningitis.

16. The nurse is teaching a client who has a spinal cord injury how to prevent respiratory problems at home. Which statement indicates that the client correctly understands the teaching? a. "I will use my incentive spirometer every 2 hours while I'm awake." b. "I will not drink thick fluids to prevent choking." c. "I will take cough medicine to prevent excessive coughing." d. "I will position myself on my right side so I don't aspirate."

ANS: A Often, the person with a spinal cord injury will have weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client expand her or his lungs more fully and prevents atelectasis. Clients should drink fluids that they can tolerate; usually thick fluids are easy to tolerate. The client should be encouraged to cough and clear secretions. Clients should be placed in high Fowler's position to prevent aspiration.

14. The nurse instructs a client who has myasthenia gravis to take prescribed medications on time and to eat meals 45 to 60 minutes after taking anticholinesterase drugs. The client asks why the timing of meals is so important. Which is the nurse's best response? a. "This timing allows the drug to have maximum effect, so it is easier for you to chew, swallow, and not choke." b. "This timing prevents your blood sugar level from dropping too low and causing you to be at risk for falling." c. "These drugs are very irritating to your stomach and could cause ulcers if taken too long before meals." d. "These drugs cause nausea and vomiting. By waiting a while after you take the medication, you are less likely to vomit."

ANS: A Skeletal muscle weakness extends to the ability to chew and swallow. Clients who have myasthenia gravis are at risk for aspiration during meals. Timing the medication so that most of the meal is eaten when the drugs have produced their peak effect enables the client to chew and swallow more easily. The medication has no effect on blood glucose levels, ulcers, or nausea.

7. A client who suffered a spinal cord injury at level T5 several months ago develops a flushed face and blurred vision. On taking vital signs, the nurse notes the blood pressure to be 184/95 mm Hg. Which is the nurse's first action? a. Palpate the area over the bladder for distention. b. Place the client in the Trendelenburg position. c. Administer oxygen via a nasal cannula. d. Perform bilateral carotid massage.

ANS: A The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate.

8. During a neurologic examination, a client demonstrates a positive Romberg's sign with eyes closed, but not with eyes open. Which condition does the nurse associate with this finding? a. Difficulty with proprioception b. Peripheral motor disorder c. Impaired cerebellar function d. Positive pronator drift

ANS: A The client who sways with eyes closed (positive Romberg's sign) but not with eyes open most likely has a disorder of proprioception and uses vision to compensate for it. The other options do not explain a positive Romberg's sign.

15. A client who has myasthenia gravis is recovering after a thymectomy. Which complication does the nurse monitor for in this client? a. Sudden onset of shortness of breath b. Swelling of the lower extremities c. Lower abdominal tenderness d. Decreased urinary output

ANS: A The complication to be alert for is pneumothorax or hemothorax. The nurse monitors the client for chest pain, sudden onset of shortness of breath, diminished chest wall expansion, decreased breath sounds, restlessness, and changes in vital signs. The other symptoms are not likely to occur or are not related to removal of the thymus.

8. The nurse assesses a client who has myasthenia gravis. Which clinical manifestation does the nurse expect to observe in this client? a. Inability to perform the six cardinal positions of gaze b. Lateralization to the affected side during the Weber test c. Absent deep tendon reflexes d. Impaired stereognosis

ANS: A The most common assessment finding in more than 90% of clients with myasthenia gravis is involvement of the extraocular muscles. The nurse observes for inability or difficulty with tests of extraocular function, such as the cardinal positions of gaze. Ptosis and incomplete eye closure also may be observed. Altered hearing and absent reflexes are not common in myasthenia gravis.

4. After performing a physical assessment on a 75-year-old client, the nurse notes that the client has a hypoactive response to a test of deep tendon reflexes. Which intervention does the nurse include in this client's plan of care? a. Assist the client with ambulation. b. Elevate the client's lower extremities. c. Apply elastic support hose. d. Massage the client's legs.

ANS: A The older adult experiences certain neurologic changes associated with aging. Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing the client to falls. The nurse or assistive personnel should assist this client with ambulation to prevent injury. The other interventions do not address the client's problem.

24. On assessment of the left plantar reflexes of an adult client, the nurse notes the response shown in the photograph below. What action does the nurse take after assessing this new finding? a. Relay this abnormal finding to other members of the health care team. b. Anticipate the need for cerebral angiography to determine the cause. c. Examine the family history for a potential genetic disorder. d. Document the finding and continue the assessment.

ANS: A This finding is a positive Babinski reflex. In clients older than 2 years of age, a positive Babinski reflex is considered abnormal and indicates central nervous system disease. The nurse should notify the health care provider and other members of the health care team because further investigation is warranted.

18. A hospitalized client with late-stage Alzheimer's disease says that breakfast has not been served. The nurse witnessed the client eating breakfast earlier. Which statement made to this client is an example of validation therapy? a. "I see you are still hungry. I will get you some toast." b. "You are confused about mealtimes this morning." c. "You ate your breakfast 30 minutes ago." d. "You look tired. Maybe a nap will help."

ANS: A Use of validation therapy involves acknowledgment of the client's feelings and concerns. This technique has proved more effective in later stages of the disease, when using reality orientation only increases agitation. Telling the client that he or she already ate breakfast may agitate the client. The other statements do not validate the client's concerns.

1. The nurse is assessing a client's coping strategies after suffering a traumatic spinal cord injury. Which information related to this assessment is important for the nurse to obtain? (Select all that apply.) a. Spiritual or religious beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies

ANS: A, C, D, F Information about the client's preinjury psychosocial status, usual methods of coping with illness, difficult situations, and disappointments should be obtained. Determine the client's level of independence or dependence and his or her comfort level in discussing feelings and emotions with family members or close friends. Clients who are emotionally secure and have a positive self-image, a supportive family, and financial and job security often adapt to their injury. Information about the client's spiritual and religious beliefs or cultural background also assists the nurse in developing the plan of care. The other options do not supply as much information about coping.

28. The nurse is assessing the results of diagnostic tests on a client's cerebrospinal fluid (CSF). Which values and observations does the nurse correlate as most indicative of viral meningitis? (Select all that apply.) a. Clear b. Cloudy c. Normal protein level d. Increased protein level e. Normal glucose level f. Decreased glucose level

ANS: A, D, E Viral meningitis does not cause cloudiness or increased turbidity of CSF. Protein levels are slightly increased, and glucose levels are normal. In bacterial meningitis, the presence of bacteria and white blood cells causes the fluid to be cloudy.

26. The nurse is assessing a client with a temporal lobe injury. Which clinical manifestations correlate with this injury? (Select all that apply.) a. Memory loss b. Personality changes c. Loss of temperature regulation d. Difficulty with sound interpretation e. Speech difficulties f. Impaired taste

ANS: A, D, E Wernicke's area (language area) is located in the temporal lobe and enables processing of words into coherent thought and understanding of written or spoken words. The temporal lobe also is responsible for the auditory center's interpretation of sound and complicated memory patterns. Personality changes are related to damage to frontal lobe injury. Loss of temperature regulation is seen with damage to the hypothalamus, and impaired taste is associated with injury to the parietal lobe.

26. The nurse is planning care for a client with epilepsy. Which precautions does the nurse implement to ensure the safety of the client while in the hospital? (Select all that apply.) a. Have suction equipment at the bedside. b. Place a padded tongue at the bedside. c. Permit only clear oral fluids. d. Keep bed rails up at all times. e. Maintain the client on strict bedrest. f. Ensure that the client has IV access.

ANS: A, D, F The bed rails should be up at all times while the client is in the bed to prevent injury from a fall if the client has a seizure. Padded tongue blades may pose a danger to the client during a seizure. Be sure that oxygen and suctioning equipment with an airway are readily available. If the client does not have an IV access, insert a saline lock, especially for those clients who are at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure.

14. The nurse is preparing a client for magnetic resonance angiography. Which question is a priority at this time? a. "Have you had a recent blood transfusion?" b. "Do you have allergies to iodine or shellfish?" c. "Do you have a history of urinary tract infections?" d. "Do you currently use oral contraceptives?"

ANS: B Allergies to iodine and/or shellfish need to be explored because the client may have a similar reaction to the dye used in the procedure. In some cases, the client may need to be medicated with antihistamines or steroids before the test is given. The other conditions would not affect the angiography.

22. The nurse is assessing a client with Huntington's disease. Which motor changes does the nurse monitor for in this client? a. Shuffling gait b. Jerky hand movements c. Continuous chewing motions d. Tremors of the hands during fine motor tasks

ANS: B An imbalance between excitatory and inhibitory neurotransmitters leads to uninhibited motor movements, such as brisk, jerky, purposeless movements of the hands, face, tongue, and legs. Shuffling gait, continuous chewing motions, and tremors are associated with Parkinson's disease.

7. The nurse is assessing a client's remote memory. Which statement by the client confirms that remote memory is intact? a. "Mary had a little lamb whose fleece was white as snow." b. "I was born on April 3, 1967, in Johnstown Community Hospital." c. "Apple, chair, and pencil are the words you just stated." d. "My sister brought me to the clinic for this appointment."

ANS: B Asking clients about certain facts from the past that can be verified assesses remote, or long-term, memory. The client's ability to make up a rhyme tests not memory, but rather a higher level of cognition. The other statements indicate immediate and recent memory.

1. The nurse is caring for a client experiencing migraine headaches who is receiving a beta blocker to help manage this disorder. When preparing a teaching plan, which instruction does the nurse plan to provide? a. "Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache." b. "Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches." c. "This drug will relieve the pain during the aura phase soon after a headache has started." d. "This medication will have no effect on your heart rate or blood pressure because you are taking it for migraines."

ANS: B Beta blockers are prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected, and the client should monitor these side effects. The other responses do not discuss an appropriate use of the medication.

6. The nurse is caring for a client who has undergone a spinal fusion. Which specific postoperative instructions does the nurse give this client? a. "You may lift items up to 10 pounds." b. "Wear your brace when you are out of bed." c. "You must remain on bedrest for 48 hours after surgery." d. "You will need to take steroids to prevent rejection of the bone graft."

ANS: B Clients who undergo spinal fusion are fitted with a brace that they need to wear throughout the healing process (usually 3 to 6 months) whenever they are out of bed. The client does not need to remain on bedrest for the first 48 hours, should not lift anything, and will not take steroids for rejection prevention

11. The nurse is assessing a client with a spinal cord injury at the T5 level. Which clinical manifestation alerts the nurse to the presence of a complication of this injury? a. Rhinorrhea and epiphora b. Fever and cough c. Agitation and restlessness d. Hip and knee pain

ANS: B Clients with injuries at or above the T6 vertebra are especially at risk for respiratory complications caused by impaired intercostal muscles. The development of fever and cough should alert the nurse to the possibility of pneumonia. The other manifestations are not related to complications from this type of injury.

4. The intensive care nurse is caring for a client who has Guillain-Barré syndrome. The nurse notes that the client's vital capacity has declined to 12 mL/kg, and the client is having difficulty clearing secretions. Which is the nurse's priority action? a. Place the client in a high Fowler's position. b. Prepare the client for elective intubation. c. Administer oxygen via a nasal cannula. d. Auscultate for breath sounds.

ANS: B Deterioration in vital capacity to less than 15 mL/kg and an inability to clear secretions are indications for elective intubation. The other interventions may assist with breathing and oxygenation but would not reverse the deterioration in vital capacity or help clear secretions.

12. Before electroencephalography, a client asks, "Why will I be asked to take deep breaths during the procedure?" How does the nurse respond? a. "Hyperventilation causes cerebral vasodilatation and increases the likelihood of seizure activity." b. "Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity." c. "Deep breathing will keep you relaxed and will lower the seizure threshold." d. "Deep breathing will make you hypoxemic, which lowers the seizure threshold."

ANS: B Hyperventilation produces cerebral vasoconstriction and alkalosis, which increases the likelihood of seizure activity. The client is asked to breathe deeply 20 to 30 times for 3 minutes. The other responses are not appropriate.

1. The nurse recognizes which pathophysiologic feature as a hallmark of Guillain-Barré syndrome? a. Nerve impulses are not transmitted to skeletal muscle. b. The immune system destroys the myelin sheath. c. The distal nerves degenerate and retract. d. Antibodies to acetylcholine receptor sites develop.

ANS: B In Guillain-Barré syndrome, the immune system destroys the myelin sheath, causing segmental demyelination. Nerve impulses are transmitted more slowly but remain in place. Antibodies are not developed. The nerves do not degenerate and retract

8. A client is actively experiencing status epilepticus. Which prescribed medication does the nurse prepare to administer? a. Atropine b. Lorazepam (Ativan) c. Phenytoin (Dilantin) d. Morphine sulfate

ANS: B Initially, intravenous lorazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atropine and morphine are not administered for seizure activity.

16. The nurse is obtaining the health history of a client scheduled for magnetic resonance imaging (MRI). Which condition requires the nurse to cancel the MRI? a. Amputated leg b. Internal insulin pump c. Intrauterine device d. Atrioventricular (AV) graft

ANS: B Metal devices such as pacemakers and prostheses interfere with the accuracy of the image and can become displaced by the magnetic force generated by an MRI procedure. An intrauterine device and an AV graft do not contain any metal.

10. A client who experienced a spinal cord injury 1 hour ago is brought to the emergency department. Which prescribed medication does the nurse prepare to administer to this client? a. Intrathecal baclofen (Lioresal) b. Methylprednisolone (Medrol) c. Atropine sulfate d. Epinephrine (Adrenalin)

ANS: B Methylprednisolone (Medrol) should be given within 8 hours of the injury. Clients who receive this therapy usually show improvement in motor and sensory function. The other medications are inappropriate for the client.

7. The nurse teaches a client with Guillain-Barré syndrome (GBS) about the recovery rate of this disorder. Which statement indicates that the client correctly understands the teaching? a. "I need to see a lawyer because I do not expect to recover from this disease." b. "I will have to take things slowly for several months after I leave the hospital." c. "I expect to be able to return to work in construction soon after I get discharged." d. "I wonder if my family will be able to manage my care now that I am paralyzed."

ANS: B Most clients make a full recovery from GBS. Recovery can take as long as 6 months to 2 years. Fatigue is a major lingering symptom for most of those diagnosed with this disorder. Clients are not permanently paralyzed. They are in an acute care environment during the acute phase of the disorder.

20. The caregiver of a client with advanced Alzheimer's disease states, "She is always wandering off. What can I do to manage this restless behavior?" How does the nurse respond? a. "Allow for a 45-minute daytime nap." b. "Take the client for frequent walks throughout the day." c. "Using a Geri-chair may decrease agitation." d. "Give a mild sedative during periods of restlessness."

ANS: B Several strategies may be used to cope with restlessness and wandering. Taking the client for frequent walks may decrease restless behavior. Another strategy is to engage the client in structured activities. The other options would not be as helpful.

12. The nurse is assessing a client who is experiencing a myasthenia crisis. Which diagnostic test does the nurse anticipate being ordered? a. Babinski reflex test b. Tensilon test c. Cholinesterase challenge test d. Caloric reflex test

ANS: B The Tensilon test in an important procedure for a client in myasthenic crisis. Cholinesterase-inhibiting drugs should be withheld because they increase respiratory secretions, which enhance the manifestations of a myasthenic crisis. A Babinski reflex and caloric reflex test would not be appropriate for this client.

1. The nurse assesses a client who has trauma to the cerebrum. Which clinical manifestation does the nurse expect to observe? a. Poor coordination b. Memory loss c. Hyperthermia d. Slurred speech

ANS: B The cerebrum is the largest part of the brain and controls intelligence, creativity, and memory. Poor coordination, hyperthermia, and slurred speech are caused by other parts of the brain.

17. The nurse assesses for which clinical manifestation in a client with multiple sclerosis (MS) of the relapsing type? a. Absence of periods of remission b. Attacks becoming increasingly frequent c. Absence of active disease manifestations d. Gradual neurologic symptoms without remission

ANS: B The classic picture of relapsing-remitting MS is characterized by increasingly frequent attacks. The other manifestations do not correlate with a relapsing type of MS.

21. The nurse is preparing a client who has multiple sclerosis (MS) for discharge home from a rehabilitation center. The client has been prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which instruction does the nurse include in the teaching plan for the client? a. "Take warm baths to promote muscle relaxation." b. "Avoid crowds and people with colds." c. "Use physical aids such as walkers as little as possible." d. "Stop using these medications when your symptoms improve."

ANS: B The client should be taught to avoid people with any type of upper respiratory illness because these medications are immunosuppressive. Warm baths will exacerbate the MS symptoms, assistive devices may be required for safe ambulation, and medication should not be stopped.

6. The nurse assesses a client with Guillain-Barré syndrome during plasmapheresis. Which complication does the nurse monitor for during this procedure? a. Tachycardia b. Hypovolemia c. Hyperkalemia d. Hemorrhage

ANS: B The client undergoing plasmapheresis is at risk for hypovolemia. The nurse monitors fluid status, assesses vital signs, and administers replacement fluid, as indicated. The other manifestations are not complications of plasmapheresis.

11. The nurse is caring for a client who has myasthenia gravis. Which nursing intervention does the nurse implement to reduce muscle weakness in this client? a. Administer a therapeutic massage. b. Collaborate with the physical therapist. c. Perform passive range-of-motion exercises. d. Reposition the client every 2 hours.

ANS: B The hallmark of myasthenia gravis is muscle weakness that increases with fatigue. The nurse provides assistance with ADLs to prevent fatigue. The nurse collaborates with the physical therapist in teaching the client energy conservation techniques. Therapeutic massage, passive range of motion, and repositioning will not reduce muscle weakness.

7. The nurse is caring for a client with a history of epilepsy who suddenly begins to experience a tonic-clonic seizure and loses consciousness. What is the nurse's priority action? a. Restrain the client's extremities. b. Turn the client's head to the side. c. Take the client's blood pressure. d. Place an airway into the client's mouth.

ANS: B The nurse should turn the client's head to the side to prevent aspiration and allow drainage of secretions. The client should not be restrained nor an airway placed in his or her mouth during the seizure because these actions increase seizure activity and can harm the client. Vital signs are measured in the postictal phase of the seizure.

20. A client with multiple sclerosis is being treated with fingolimod (Gilenya). Which clinical manifestation alerts the nurse to an adverse effect of this medication? a. Periorbital edema b. Black tarry stools c. Bradycardia d. Vomiting after meals

ANS: C Fingolimod (Gilenya) is an antineoplastic agent that can cause bradycardia, especially within the first 6 hours after administration. The other manifestations are not adverse effects of fingolimod.

2. The nurse is teaching a client with a spinal cord tumor about the treatment plan. Which statements indicate that the client correctly understands the teaching? (Select all that apply.) a. "Because my symptoms occurred so quickly, I am likely to be cured quickly by surgery." b. "Radiation therapy can shrink the tumor but radiation can cause more problems, too." c. "I am glad you are here to turn me. Lying in one position for a long time makes my pain worse, even if turning is uncomfortable." d. "I have put my affairs in order and purchased a burial plot because this type of cancer is almost always fatal." e. "My family is making some changes at home for me, including moving my bedroom downstairs."

ANS: B, C, E Although surgery may relieve symptoms by reducing pressure on the spine and debulking the tumor, some motor and sensory deficits may remain. Spinal tumors usually cause disability but are not usually fatal.

27. The nurse is administering a medication to a client that stimulates the sympathetic division of the autonomic nervous system. Which clinical manifestations does the nurse monitor for? (Select all that apply.) a. Decreased heart rate b. Increased heart rate c. Decreased force of contraction d. Increased force of contraction e. Decreased respirations

ANS: B, D Stimulation of the sympathetic nervous system initiates the fight-or-flight response, increasing both the heart rate and the force of contraction. The other three options do not occur with sympathetic nervous system stimulation.

3. The nurse is teaching a male client with a spinal cord injury at T4 (thoracic) about the sexual effects of this injury. Which statement by the client indicates correct understanding of the teaching? (Select all that apply.) a. "I will not be able to have an erection because of my injury." b. "Ejaculation may not be as predictable as before." c. "I will explore other ways besides intercourse to please my partner." d. "I may urinate with ejaculation but this will not cause an infection." e. "I should be able to have an erection with stimulation."

ANS: B, D, E Men with injuries above T6 often are able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the client's partner will not get an infection.

27. The nurse is teaching a client with chronic headaches about headache triggers. Which statements does the nurse include in the client's teaching plan? (Select all that apply.) a. "Increase your intake of caffeinated beverages." b. "Increase your intake of fruits and vegetables." c. "Avoid all alcoholic beverages." d. "Avoid drinking red wine." e. "Incorporate physical exercise into your daily routine." f. "Incorporate an occasional fast into your plan."

ANS: B, D, E Triggers for headaches include caffeine, smoking, and ingestion of pickled foods. Clients are taught to eat a balanced diet and to get adequate exercise and rest.

16. A client with Alzheimer's disease is admitted to the hospital. Which psychosocial assessment is most important for the nurse to complete? a. Ability to recall past events b. Ability to perform self-care c. Reaction to a change of environment d. Relationship with close family members

ANS: C As the disease progresses, the client experiences changes in emotional and behavioral affect. The nurse should be alert to the client's reaction to a change in environment, such as being hospitalized, because the client may exhibit an exaggerated response, such as aggression, to the event. The other assessments should be completed but are not as important for a client with Alzheimer's disease.

25. The nurse is caring for a client who has chronic migraine headaches. Which complementary health therapy does the nurse suggest? a. "Place a hot compress on your forehead at the onset of the headache." b. "Wear dark sunglasses when you are in brightly lit spaces." c. "Lie down in a darkened room when you experience a headache." d. "Do not sleep longer than 6 hours at one time."

ANS: C At the onset of a migraine attack, the client may be able to alleviate pain by lying down and darkening the room. He or she may want both eyes covered and a cool cloth on the forehead. If the client falls asleep, he or she should remain undisturbed until awakening. The other options are not recognized therapies for migraines.

23. The nurse is assessing a client scheduled for a lumbar puncture. Which clinical manifestation assessed by the nurse complicates the lumbar puncture procedure? a. Normal intracranial pressures b. Allergy to iodine or shellfish c. Restlessness and agitation d. Eating lunch less than 2 hours ago

ANS: C Clients must be able to hold still during the procedure. If a client is restless or agitated, assistance may be needed to ensure that the procedure is completed safely. Lumbar puncture is not performed on clients with severely high intracranial pressure. Allergies to iodine and shellfish or eating lunch 2 hours before the procedure have no effect on the procedure.

21. A client who has Alzheimer's disease is being discharged home. What safety instructions does the nurse include in the teaching plan for the client's caregiver? a. "Keep exercise to a minimum." b. "Place a padded throw rug at the bedside." c. "Install deadbolt locks on all outside doors." d. "Keep the lights off in the bedroom at night."

ANS: C Clients with Alzheimer's disease have a tendency to wander, especially at night. If possible, alarms should be installed on all outside doors to alert family members if the client leaves. At a minimum, all outside doors should have deadbolt locks installed to prevent the client from going outdoors unsupervised. The client should be allowed to exercise within his or her limits. Throw rugs are a slip and fall hazard and should be removed. The client may need or want lights on in the bedroom at night.

11. The nurse is evaluating a client's physical assessment with the medical history and treatment plan. The nurse notes that the client's right pupil appears dilated, with a sluggish pupillary response to light. Which disorder and related treatment does this physical finding correlate with? a. Coronary artery disease and beta blockers b. Diabetes mellitus and oral glycemic reducing agents c. Glaucoma and intraocular pressure-reducing eyedrops d. Myopia and corrective laser surgery

ANS: C Clients with glaucoma who are being treated with eyedrops have unequal pupils, especially if only one eye is being treated. The pupillary reaction to light is slowed by the use of eyedrops for glaucoma. The other disorders and treatments do not correlate with the clinical assessment.

19. The nurse is planning care for an 83-year-old client with age-related changes to his sensory perception. Which nursing action does the nurse implement to ensure the client's safety? a. Provide a call button that requires only minimal pressure to activate. b. Use a clock and a calendar to orient and minimize onset of dementia. c. Ensure that the path to the bathroom is free from equipment. d. Admit the client to the room closest to the nursing station.

ANS: C Dementia and confusion are not common phenomena in older adults. However, physical impairment related to illness can be expected. Providing opportunities for hazard-free ambulation will maintain strength and mobility (and ensure safety). The other actions are not a priority.

18. The nurse is assessing a client with an early onset of multiple sclerosis (MS). Which clinical manifestation does the nurse expect to see? a. Hyperresponsive reflexes b. Excessive somnolence c. Nystagmus d. Heat intolerance

ANS: C Early signs and symptoms of MS include changes in motor skills, vision, and sensation. The other manifestations are later signs of MS.

2. The nurse is assessing a client with a history of migraines. Which clinical manifestation is an early sign of a migraine with aura? a. Vertigo b. Lethargy c. Visual disturbances d. Numbness of the tongue

ANS: C Early warning of impending migraine with aura usually consists of visual changes, flashing lights, or diplopia. The other manifestations are not associated with an impending migraine with aura.

2. The nurse is caring for a client who has low back pain (LBP) from a work-related injury. Which measures does the nurse incorporate into the client's plan of care? a. Apply moist heat continuously to the affected area. b. Use ice packs or ice massage for 1 to 2 hours over the affected area. c. Apply heat packs for 20 to 30 minutes at least four times daily. d. Advise the client to avoid hot baths or showers.

ANS: C Heat increases blood flow to the affected area and promotes healing of injured nerves. However, continuous application of moist heat can promote skin breakdown.

15. The nurse is caring for a client who had a computed tomography (CT) scan of the head with contrast medium. Which priority intervention does the nurse implement? a. Maintain bedrest with the head of the bed elevated less than 30 degrees. b. Apply a pressure dressing to the site of injection. c. Increase fluid intake after the procedure. d. Maintain sedation for 8 hours postprocedure.

ANS: C If a contrast medium is used, intravenous fluid may be given to promote excretion of the contrast medium. Contrast medium also may act as a diuretic, resulting in the need for fluid replacement. The client will not be sedated for the procedure and will not require bedrest. Contrast is injected through a peripheral IV.

5. A client who has Guillain-Barré syndrome is scheduled for plasmapheresis. Before the procedure, which clinical manifestation does the nurse use to determine patency of the client's arteriovenous shunt? a. Palpable distal pulses b. A pink, warm extremity c. The presence of a bruit d. Shunt pressure higher than 25 mm Hg

ANS: C Nursing care of the client undergoing plasmapheresis includes care of the shunt. The nurse checks for bruits every 2 to 4 hours for patency. Pulse and extremity assessments do not provide information related to shunt patency. Pressure within the shunt is not tested before treatment to determine patency.

5. The nurse is discharging an 80-year-old client with diminished touch sensation. Which instruction does the nurse provide to promote client safety? a. "Walk barefoot only in your home." b. "Bathe in warm water to increase your circulation." c. "Look at the placement of your feet when walking." d. "Put throw rugs at the foot of your bed for cushioning."

ANS: C Older clients with decreased sensation are at risk of injury from the inability to sense changes in terrain when walking. To compensate for this loss, the client is instructed to look at the placement of her or his feet when walking. The client also should wear sturdy shoes for ambulation. Throw rugs can slip and increase fall risk. Bath water that is too warm places the client at risk for thermal injury.

15. A client with paraplegia is scheduled to participate in a rehabilitation program. The client states, "I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better." How does the nurse respond? a. "If you do not want to participate in the rehabilitation program, I will cancel the order." b. "Your doctor has helped many clients with your injury and has ordered a rehabilitation program to help you." c. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." d. "When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first."

ANS: C Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of functional ability, and restoration of function. The other responses do not meet the client's needs.

12. The nurse notes reddened areas over the hips and sacrum of a client with paraplegia from a spinal cord injury. Which action does the nurse implement? a. Massage the reddened areas with a barrier cream. b. Perform hip flexion and extension range-of-motion (ROM) exercises. c. Reposition the client so that the reddened area does not bear weight. d. Ensure that the client sits in a chair at least once each shift.

ANS: C Reddened areas should not be rubbed because this action could cause more extensive damage to the already fragile capillary system. ROM exercises are used to prevent contractures. The reddened areas should be assessed for blanching. If the skin does not blanch, the area is vulnerable to breakdown. Appropriate interventions to relieve pressure on these areas through positioning, assistive devices, and skin protection should then be used.

25. The nurse is teaching a client who has an unstable thoracic vertebral fracture and is being treated with immobilization before surgery. Which statement does the nurse include in the client's teaching? a. "You will need to apply an immobilizing brace snugly around your waist when out of bed." b. "You will remain strapped to the transport back board until the surgical room is ready." c. "Keep your spine in alignment by not sitting up, arching your back, or twisting in bed." d. "An incentive spirometer will prevent you from having atelectasis and pneumonia after surgery."

ANS: C The client with a thoracic vertebral fracture is at risk for spinal cord injury, especially with flexion, extension, or rotation of the trunk. The client will be moved to a more comfortable bed to wait for surgery and will remain on bedrest. Although teaching about how to use an incentive spirometer is important for surgical clients, the incentive spirometer alone does not prevent atelectasis and pneumonia; it only assists the client to breathe deeply.

18. The nurse is planning discharge teaching for a client who has peripheral neuropathy of the lower extremities. Which instruction does the nurse include in the teaching plan? a. "Cut all calluses and corns from your feet as soon as you notice them." b. "Your balance will be steadier if you go barefoot while at home." c. "Use a thermometer to check the temperature of bath water." d. "Avoid using lotion on the feet and legs."

ANS: C The client with neuropathy has loss of sensation in the lower extremities, which can predispose the client to thermal injury. The client should be instructed to use a thermometer to check the temperature of the bath water to avoid a burn. Checking the water with the hands is not recommended because neuropathy may have a stocking and glove distribution that could also affect the hands. The client should be taught to wear shoes at all times, to assess feet and legs daily, to keep skin moist and clean, and not to cut calluses or corns from the feet.

2. The nurse is assessing a client with a frontal lobe brain injury. Which clinical manifestation does the nurse expect to see? a. Inability to interpret taste sensations b. Inability to interpret sound c. Impaired judgment d. Impaired learning

ANS: C The frontal lobe is responsible for many functions, including judgment, reasoning, voluntary eye movement, and motor functions. The other clinical manifestations are not associated with the frontal lobe.

2. The nurse assesses a client who has Guillain-Barré syndrome. Which clinical manifestation does the nurse expect to find in this client? a. Ophthalmoplegia and diplopia b. Progressive weakness without sensory involvement c. Progressive, ascending weakness and paresthesia d. Weakness of the face, jaw, and sternocleidomastoid muscles

ANS: C The most common clinical pattern of Guillain-Barré syndrome is the ascending variety. Weakness and paresthesia begin in the lower extremities and progress upward. The other manifestations are not associated with Guillain-Barré syndrome.

9. The nurse is caring for a client who has a vertebral fracture. Which intervention does the nurse implement to prevent deterioration of the client's neurologic status? a. Reorient the client to time, place, and person. b. Administer the Mini-Mental State Examination. c. Immobilize the affected portion of the spinal column. d. Reposition the client every 2 hours.

ANS: C The nurse keeps the client in optimal body alignment at all times, avoiding flexion and extension at the site of vertebral injury, to prevent further cord injury or irritability from bone fragments. A brace, traction, or external fixation may be used for this purpose. The other interventions would not prevent deterioration of the client's neurologic status. Assessments would assist with the recognition of neurologic changes but would not prevent them.

26. The nurse is planning care for a client who has a spinal cord injury. Which interdisciplinary team member does the nurse consult with to assist the client with activities of daily living? a. Social worker b. Physical therapist c. Occupational therapist d. Case manager

ANS: C The occupational therapist instructs the client in the correct use of all adaptive equipment. In collaboration with the therapists, the nurse instructs family members or the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin care. The other team members are consulted to assist the client with unrelated issues.

5. A client with epilepsy develops stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How does the nurse document this seizure activity? a. Atonic seizure b. Absence seizure c. Myoclonic seizure d. Tonic-clonic seizure

ANS: D Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. The other seizures do not manifest in this manner.

16. A client with myasthenia gravis is preparing for discharge. Which instructions does the nurse include when educating the client's family members or caregiver? a. Technique for therapeutic massage to the lower extremities b. Administration of morphine sulfate via an IV pump c. Instructions for preparing thin, puréed foods d. Cardiopulmonary resuscitation (CPR)

ANS: D Respiratory compromise is a common occurrence with myasthenia gravis. The client's family members are encouraged to learn CPR and to have resuscitation equipment available in the home. The other interventions are not a priority.

6. A client admitted the previous day for a suspected neurologic disorder becomes increasingly lethargic. Which is the best nursing action? a. Promote a quiet atmosphere for sleep and rest to treat the client's sleep deprivation. b. Explain to the family that this is a normal age-related decline in mental processing. c. Consult a psychiatrist to treat the client's hospital-acquired depression. d. Complete a full neurologic assessment and notify the neurologist.

ANS: D A change in the client's level of consciousness (LOC) is the first indication of a decline in central neurologic functioning. The nurse should conduct a thorough assessment and then should notify the neurologist (or other provider). The other interventions are inappropriate.

13. The nurse is talking to the family of a client who has Parkinson's disease. Which statement indicates that the family has a good understanding of the changes in motor movement associated with this disease? a. "I can never tell what she's thinking. She hides behind a frozen face." b. "She drools all the time so I just can't take her out anywhere." c. "I think this disease makes her nervous. She perspires all the time." d. "She has trouble chewing so I will offer bite-sized portions."

ANS: D A masklike face, drooling, and excess perspiration are common in clients with Parkinson's disease. Changes in facial expression or a masklike facies in a Parkinson's disease client can be misinterpreted. Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the client's nutritional needs. The other statements indicate poor understanding of the disease process.

9. A client with new-onset status epilepticus is prescribed phenytoin (Dilantin). After teaching the client about this treatment regimen, the nurse assesses the client's understanding. Which statement indicates that the client understands the teaching? a. "I must drink at least 2 liters of water daily." b. "This will stop me from getting an aura before a seizure." c. "I will not be able to be employed while taking this medication." d. "Even when my seizures stop, I will take this drug."

ANS: D Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can continue to work while taking this medication. The medication will not stop an aura before a seizure.

15. The daughter of a client with Alzheimer's disease asks, "Will the medication my mother is taking improve her dementia?" How does the nurse respond? a. "It will help your mother live independently once more." b. "It is used to halt the advancement of Alzheimer's disease but will not cure it." c. "It will provide a steady improvement in memory but not in problem solving." d. "It will not improve dementia but can help control emotional responses."

ANS: D Drug therapy is not effective for treating dementia or halting the advancement of Alzheimer's disease. However, certain drugs may help suppress emotional disturbances and psychiatric manifestations.

14. The nurse is caring for a client with Parkinson's disease. Which intervention does the nurse implement to prevent respiratory complications in the client? a. Keep an oral airway at the bedside. b. Ensure fluid intake of at least 3 L/day. c. Teach the client pursed-lip breathing techniques. d. Maintain the head of the bed at 30 degrees or greater.

ANS: D Elevation of the back rest will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson's disease.

14. A client who has a lower motor neuron injury experiences a flaccid bowel elimination pattern. Which action does the nurse implement to assist in relieving this client's constipation? a. Pouring warm water over the perineum b. Tapping the abdomen from left to right c. Administering daily tap water enemas d. Implementing a consistent daily time for elimination

ANS: D For the client with a lower motor neuron injury, the resulting flaccid bowel may require a bowel program for the client, which includes stool softeners, increased fluid intake, a high-fiber diet, and a consistent elimination time. The other interventions do not assist this client.

22. Early manifestations of amyotrophic lateral sclerosis (ALS) and multiple sclerosis (MS) are somewhat similar. Which clinical feature of ALS distinguishes it from MS? a. Dysarthria b. Dysphagia c. Muscle weakness d. Impairment of respiratory muscles

ANS: D In ALS, progressive muscle atrophy occurs until a flaccid quadriplegia develops. Eventually, the respiratory muscles are involved, and this leads to respiratory compromise.

13. The nurse is caring for a client with a lower motor neuron lesion who wishes to achieve bladder control. Which intervention does the nurse implement to effectively stimulate the initiation of voiding for this client? a. Stroking the inner aspect of the thigh b. Intermittent catheterization c. Digital anal stimulation d. The Valsalva maneuver

ANS: D In clients with lower motor neuron problems, such as spinal cord injury, performing a Valsalva maneuver or tightening the abdominal muscles are interventions that can initiate voiding. The other interventions do not initiate voiding.

4. The nurse is assessing a client who had a discectomy 6 hours ago. Which client complaint requires priority action by the nurse? a. "I am feeling tired." b. "My mouth is so dry." c. "I can't seem to relax and rest." d. "I am unable to urinate."

ANS: D Inability to void may indicate damage to the sacral spinal nerves. The other symptoms require the nurse to provide care but are not the priority or a complication of the procedure.

18. A female client with deteriorating neurologic function states, "I am worried I will not be able to care for my young children." How does the nurse respond? a. "Caring for your children is a priority. You may not want to ask for help, but you have to." b. "Our community has resources that may help you with some household tasks so you have energy to care for your children." c. "You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?" d. "Give me more information about what worries you, so we can see if we can do something to make adjustments."

ANS: D Investigate specific concerns about situational or role changes before providing additional information. The nurse should tell the client what is or is not a priority for her. Although community resources may be available, they may not be appropriate for the client. Consulting a psychologist would not be appropriate.

24. A client is scheduled for magnetic resonance imaging (MRI). Which action does the nurse implement before the test? a. Ensure that the person does not eat for 8 hours before the procedure. b. Discontinue all neuroactive medications 3 hours before the procedure. c. Make sure that the client has an identification bracelet that cannot be removed. d. Replace the client's gown with metal snaps with one that has cloth ties.

ANS: D Metal objects are a hazard because of the magnetic field used in the MRI procedure. The other actions are not necessary for MRI.

19. A client presents with an acute exacerbation of multiple sclerosis. Which prescribed medication does the nurse prepare to administer? a. Baclofen (Lioresal) b. Interferon beta-1b (Betaseron) c. Dantrolene sodium (Dantrium) d. Methylprednisolone (Medrol)

ANS: D Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other medications are not appropriate.

21. The nurse is teaching a client before magnetic resonance imaging (MRI). Which statement indicates that the client understands the content of the education? a. "I need to stay away from heavy metals for the next 48 hours." b. "My urine will be radioactive for the next 48 hours." c. "I must increase my fluids because of the dye used for the MRI." d. "I can return to my usual activities immediately after the MRI."

ANS: D No postprocedure restrictions are imposed after MRI. The client can return to normal activities after the test is complete.

11. The nurse assesses for which clinical manifestations in the client with suspected encephalitis? a. Fever of 101° F (38.3° C) b. Nausea and vomiting c. Hypoactive deep tendon reflexes d. Pain on flexion of the neck

ANS: D Nuchal rigidity is associated with meningeal irritation and is frequently present in clients with encephalitis. The other manifestations are not associated with encephalitis.

9. The nurse is assessing laboratory results for a client with myasthenia gravis (MG). Which results does the nurse correlate with this disease process? a. Elevated serum calcium level b. Decreased thyroid hormone level c. Decreased complete blood count d. Elevated acetylcholine receptor antibody levels

ANS: D Testing for acetylcholine receptor (AChR) antibodies is important because 80% to 90% of clients with the disease have elevated AChR antibody levels. The other laboratory results are not associated with myasthenia gravis.

5. The nurse is providing discharge teaching to a client after a lumbar laminectomy. For which complication does the nurse instruct the client to return to the hospital? a. Pain at the incision site b. Decreased appetite c. Slight redness and itching at the incision site d. Clear drainage from the incision site

ANS: D The finding of clear fluid on the dressing after a laminectomy strongly suggests a cerebrospinal fluid leak, which constitutes an emergency. The client has in increased risk of meningitis with a spinal fluid leak. Pain, redness, and itching at the site are normal. The client should be encouraged to eat a healthy diet but does not need to return to the hospital for a decreased appetite.

8. Emergency medical services arrive to the emergency department with a client who has a cervical spinal cord injury. Which priority assessment does the emergency department nurse perform at this time? a. Level of consciousness and orientation b. Heart rate and rhythm c. Muscle strength and reflexes d. Respiratory pattern and airway

ANS: D The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation. The other assessments should be performed after airway and breathing are assessed.

10. The nurse is teaching a client who is newly diagnosed with epilepsy. Which statement by the client indicates a need for further teaching concerning the drug regimen? a. "I will not drink any alcoholic beverages." b. "I will wear a medical alert bracelet." c. "I will let my doctor know about all of my prescriptions." d. "I can skip a couple of pills if they make me ill."

ANS: D The nurse must emphasize that antiepileptic drugs must be taken even if seizure activity has stopped. Discontinuing the medication can predispose the client to seizure activity and status epilepticus. The client should not drink alcohol while taking seizure medications. The client should wear a medical alert bracelet and should make the doctor aware of all medications to prevent complications of polypharmacy.

24. A client diagnosed with the Huntington gene but who has no symptoms asks for options related to family planning. Which is the nurse's best response? a. "Most clients with the Huntington gene do not pass on Huntington disease to their children." b. "I understand that they can diagnose this disease in embryos. Therefore you could select a healthy embryo from your fertilized eggs for implantation to avoid passing on Huntington disease." c. "The need for family planning is limited because one of the hallmarks of Huntington disease is infertility." d. "Tell me more specifically what information you need about family planning so that I can direct you to the right information or health care provider."

ANS: D The presence of the Huntington gene means that the trait will be passed on to all offspring of the affected person. Understanding options for contraception and conception (e.g., surrogate mother options) and implications for children may require the expertise of a genetic counselor or a reproductive specialist. The other options are not accurate.